Please provide the dates of your experience with the approximate miles driven
List out the date, nature of accident, location, number of fatalities and number injuries.
Date of Accident / Nature of Accident / Location / Number of Fatalities / Number of Injuries
Please include CMV and Non-CMV convictions.
Date / Location / Charge / Penalty
List each driver's license held in the past three years.
State / License # / Type / Endorsements / Expiration Date
It is agreed and understood that any misrepresentation given on this application shall be considered an act of dishonesty.
It is agreed and understood that the motor carrier or his agents may investigate the applicant’s background to ascertain any and all information of concern to applicant’s record, whether same is of record or not, and applicant releases employers and persons named herein from all liability for any damages on account of his furnishing such information.
It is also agreed and understood that under the Fair Credit Reporting Act, Public Law 91-508, I have been told that this investigation may include an investigating Consumer Report, including information regarding my character general reputation, personal characteristics and mode of living.
I agree to furnish such additional information and complete such examinations as may be required to complete my application file.
It is agreed and understood that this Application in no way obligates the motor carrier to employ or hire the applicant.
It is agreed and understood that if qualified and hired, I may be on a probationary period during which time I may be disqualified without recourse.
This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.